Many with cancer pain aren't on strong painkillers

NEW YORK (Reuters Health) - Despite suffering severe pain, about one in three older cancer patients do not end up taking opioids, the most potent of analgesics, according to a new study from Canada.

It's not clear why these patients are not getting their pain treated with opioids, which include morphine, oxycodone and fentanyl. It could be that physicians are not prescribing the medications or that patients are getting prescriptions, but not filling them.

"They don't have to be in pain. There's effective treatment out there," said Dr. Paul Glare, the chief of Pain and Palliative Care Service at Memorial Sloan Kettering Cancer Center in New York, who was not involved in this study.

The researchers gathered information over two years on all cancer patients over age 65 in Ontario, Canada who had been screened for pain.

Of more than 24,000 people included in the study, 20 percent reported that they had severe pain.

The team looked to see how many of them got a prescription filled for an opioid painkiller, also known as a narcotic.

A third of the high-pain group did not fill a prescription within either the month before the pain screening or the week after.

"I'm not sure I know what the number should have been, but I think I was hoping it would have been a smaller number than that," said Dr. Lisa Barbera, the lead author of the study and a researcher at Sunnybrook Health Sciences Centre in Toronto.

Glare said he would like to see the number closer to three percent.

WOMEN, ELDERLY LESS LIKELY

Older patients and women were less likely to have filled a prescription than younger patients or men.

People over age 85, for instance, were 30 percent less likely to have opioid pain treatment than people between 64 and 74 years old.

And the women in the study were 14 percent less likely to have a prescription filled than the men.

One of the reasons that patients might not fill a prescription is because of barriers like cost or not having health insurance or not having access to health care.

Barbera and her colleagues report in the Journal of Clinical Oncology that these aren't issues because all of the people in the study are covered by government-funded health insurance that pays for these medications.

Additionally, "all patients were interacting with their healthcare system, so I don't think that's the explanation," Barbera told Reuters Health.

"So the thought would be, it's something about the physician -- maybe their knowledge about pain management, their willingness to delve deeper into a patient's report of significant pain, maybe their knowledge about using these medications" that would stop them from writing a prescription in the first place, Barbera speculated.

In older patients in particular, concerns about drowsiness, falling down and delirium might lead to some hesitation in either prescribing the drugs or taking them.

Glare said pain medication should still be prescribed to older patients, but they need to be monitored more closely, and perhaps some busy physicians are not willing to take the extra time.

Some doctors might also be less eager to prescribe narcotics because of reports about over-prescribing, abuse or overdosing (see Reuters Health report of June 13, 2011).

At the same time that deaths from opioids have increased, prosecutions against doctors have too (see Reuters report of September 14, 2011).

"It's possible physicians may wrongly fear being sued" for prescribing narcotics, he said. "But the reality is they're more likely to be sued if they don't."

Glare said there have been instances of families suing doctors for not treating a patient's pain.

However, patients themselves could also stand in the way of relief.

Glare said the findings could also include people who are offered a prescription for opioids to ease their pain, but who don't want to take them for fear of side effects, addiction, or the stigma of taking a narcotic.

"Patients shouldn't be afraid of taking their pain medication. If they're having it supervised by someone they can be sure it's being prescribed safely and effectively," Glare said.

He and Barbera said they'd expect to see similar findings in the United States.

"Unfortunately...most of the studies previously demonstrate similar findings in that patients with cancer who have pain don't seem to be adequately treated," Barbera said.

Glare said if patients feel their pain is not being addressed by their doctor, they should ask to see a pain specialist for treatment.